A STUDY ON INTERNET IMPACT IN BUSINESS DESIGNS FOR THE HEALTH SECTOR

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1 UNIVERSIDADE TÉCNICA DE LISBOA INSTITUTO SUPERIOR TÉCNICO A STUDY ON INTERNET IMPACT IN BUSINESS DESIGNS FOR THE HEALTH SECTOR CARLOS MANUEL VALENTE QUITERIO SIMÃO (Licenciado em Engenharia Electrotécnica e de Computadores) Dissertação para obtenção do Grau de Mestre em Engenharia e Gestão de Tecnologia Orientador Doutor RUI MIGUEL LOUREIRO NOBRE BAPTISTA Constituição do Júri Presidente: Doutor MANUEL FREDERICO TOJAL DE VALSASSINA HEITOR Vogais: Doutor PEDRO LUÍS DE OLIVEIRA MARTINS PITA BARROS Doutor PEDRO FILIPE TEIXEIRA DA CONCEIÇÃO Doutor RUI MIGUEL LOUREIRO NOBRE BAPTISTA Agosto 2001

2 Abstract Title: A study on Internet impact in business designs for the health sector Name: Carlos Manuel Valente Quiterio Simão Master course in: Engineering and Management of Technology Oriented by: Rui Miguel Baptista (invited auxiliary professor) Concluded proof at: August 2001 Health care as become one of the most largest and dynamic industries, in terms of job creation, innovation and expenditure. There have been impressive achievements in improve health quality of populations, life expectancy and universal convergence. There remains however recurrent concerns regarding the adequacy of resources and the way they are currently used. How best to increase the equity, efficiency and effectiveness of health care. Internet emerged in the last years as a new robust interactive channel, supporting all the characteristics to be used as a self-service long distance channel, and as enabler of closer relation between business partners. Being highly interactive and offering global reach it allows real time answers to consumers requests, all over the world. Internet introduction in the health care sector, although likely, has been a slow process, much slower that among other industries. Although technology concerns did exist, as well as a strong height in the role of human relations, institutional barriers are commonly pointed as a major reason for Internet slow adoption. This new health web-enabled environment, e-health, is pushing medicine practice into an information supported, patient-centred and just-in time global market activity. The full impact in traditional health economy, is still to be measured. Nevertheless it has already changed the balance of power among health sector players, modifying the rules of operations for the entire spectrum of those involved. Including consumers, health providers, managed care organisations, pharmaceutical entities, medical equipment manufacturers and suppliers, telecommunications operators, technology developers and integrators, consultants, health funders, insurance companies, and policy makers. Through a literature review of traditional business models and Internet impact among other sectors, as well as by analysing the health market structure, and the present impact of Telemedicine in developed and developing markets, like the US and EU, it s aim to understand Internet s impact in the health care sector. Namely in enabling the access to Page 2

3 better services through lower costs, and in changing the balance of power among sector players, driving to new business practices. Key-words: e-health, Internet, business models, Telemedicine, legislation. Page 3

4 Resumo Título: Estudo do impacto da Internet nos modelos de negocio, do sector da Saúde. Nome: Carlos Manuel Valente Quiterio Simão Curso de Mestrado em: Engenharia e Gestão de Tecnologia Orientador: Rui Miguel Baptista (professor auxiliar convidado) Provas concluídas em: Agosto 2001 A industria da saúde tem-se afirmado como uma das maiores e mais dinâmicas da actualidade, em termos de criação de emprego, inovação e despesa. Alcançaram-se melhorias impressionantes na qualidade de saúde das populações, no aumento da expectativa de vida, e na convergência para padrões de saúde universais. No entanto, preocupações recorrentes como a adequação dos recursos e a sua correcta utilização, ou como promover a igualdade e o acesso a serviços de saúde mais eficazes, continuam a existir. Paralelamente, nos últimos anos, a Internet assumiu-se como um novo canal de comunicação para massas. Robusta, com cobertura global e altamente interactiva, oferece condições para ser utilizada como um canal self-service de longa distancia. Um facilitador de relações, com largo impacto entre parceiros de negócio. A introdução da Internet no sector da saúde, embora esperada, tem sido um processo lento. Muito mais lento do que em outras industrias. Embora a actividade da saúde se caracterize por fortes relações humanas e presenciais, bem como algumas preocupações tecnológicas tenham existido e continuem a existir, as barreiras institucionais e legislativas são normalmente apresentadas como o maior entrave á lenta adopção da Internet. Apesar disso, em muitos países a saúde vive já um ambiente web-enabled, que está a conduzir a pratica da medicina na direcção de uma actividade global, suportada na informação, centrada no paciente, e com relações just-in-time. O impacto global na economia da saúde ainda esta por medir. Apesar disso as mudanças no equilíbrio de poder e nas relações entre os intervenientes do sector, já são visível. Afectando consumidores, prestadores de serviços, entidades da industria farmacêutica, fabricantes de equipamentos, operadores de telecomunicações, entidades gestoras, seguradoras e governos. Através de uma revisão de literatura focada na realidade de países desenvolvidos e em desenvolvimento, como os EUA e os parceiros da Comunidade Europeia, serão Page 4

5 consideradas as alterações decorrentes da introdução da Internet em outros sectores, analisadas diferentes estruturas do mercado de saúde, e avaliado o impacto da Telemedicina na prestação de serviços e cuidados de saúde. Com base nesta metodologia, pretende-se compreender e avaliar o impacto da introdução da Internet no sector da saúde. Nomeadamente na dinamização do acesso a melhores serviços a mais baixo custo e nas alterações causadas nos modelos de negocio e relações entre os intervenientes do sector. Palavras-chave: e-health, Internet, modelos de negocio, Telemedicine, legislação. Page 5

6 Acknowledgements To my mentor, Professor Rui M. Baptista, for is objective guiding and support. To all those whose contribute to this dissertation, by sharing opinions and experiences, have been fundamental. Page 6

7 Table of Contents Abstract... 2 Resumo... 4 Acknowledgements... 6 Table of Contents... 7 Index of Figures... 9 Index of Tables I. CHAPTER I - INTRODUCTION I.1. Health markets - General overview I.1.1. US Health Sector I.1.2. EU Health Sector I.1.3. Demand Offer relation I.1.4. Health expenditure I.1.5. Market trends I.2. Internet - General overview I.2.1. Technology issues I.2.2. M-Internet I.2.3. Legislation I.2.4. Products and services I.2.5. Costs and prices I.2.6. E-commerce and business designs I.2.7. Sector impacts Research Questions II. CHAPTER II TELEMEDICINE II.1. Changes in the Market Structure II.1.1. Health Providers II.1.2. Telecom Operators II.2. Telemedicine Initiatives II.2.1. Life Signs Monitoring II.2.2. Remote Consulting II.2.3. Electronic Medical Records II.3. Costs and Benefits II.3.1. Patients Satisfaction II.3.2. Profitability II.4. Market Trends II.4.1. Market Development Stage II.4.2. Driving Forces II.4.3. Barriers to Change II.4.4. Political implications III. CHAPTER III INTERNET IN THE HEALTH SECTOR III.1. Changes in the Market Structure III.1.1. E-health Consumers III.1.2. E-Health Providers III.1.3. Insurance Companies III.1.4. Telecom Operators Page 7

8 III.2. E-health Initiatives III.2.1. Online Health Information III.2.2. Online Support Groups III.2.3. Remote monitoring of Chronic Conditions III.2.4. Online Consultation III.2.5. Online Continuos Medical Education III.2.6. Online Contact Centres III.2.7. Electronic Medical Records III.2.8. Electronic Procurement III.2.9. Health Portals III.3. E-value proposition for Pharmaceutics Industry III.3.1. Online Drugs Advertising III.3.2. Online Prescription III.3.3. E-Pharmacy III.4. Costs and Benefits III.4.1. Potential assessment proposal III.5. Market Trends III.5.1. Market development Stage III.5.2. Driving Forces III.5.3. Barriers to Change III.5.4. Political implications IV. CHAPTER IV DISCUSION AND CONCLUSIONS Glossary References Appendices Appendix A: EU, health sector market structures UK Health Sector French Health Sector Denmark Health Sector Swedish Health Sector Portuguese Health Sector EU financing models and sources of funding: Appendix B: Telemedicine Technology Appendix C: E-health services assessment Appendix D: Portuguese E-health Experiences Page 8

9 Index of Figures Figure 1. Health sector structures. Source: Béresniak and Duru (1999) Figure 2. Typology of the public health care systems in the EU. Source: Palm et al (2000) Figure 3. Per Capita expenditure on health, Source: OECD Health data Figure 4. Government legislative role. Source: Westland and Cark (2000) Figure 5. Digitised Vs. Physical products Figure 6. Commercial transaction variables Figure 7. Internet impact in price structure variables Figure 8. E-Commerce costs Figure 9. Traditional supply chain. Source: Bovet and Martha Figure 10. Value net. Source: Bovet and Martha Figure 11. Internet business models matrix Figure 12. Internet business value chain Figure 13. Internet disintermediation Figure 14. Telemedicine players Figure 15. Hospital - 3 rd part connections Figure 16. Telecom operators migration, along Telemedicine the value chain Figure 17. Chronic patients / LSM Business model Figure 18. Telemedicine expectations Figure 19. Costs variation Figure 20. Challenges facing Telemedicine Figure 21. Health sector evolution. Source: Lere Figure 22. How health players use Internet Figure 23. E-health consumer. Source: Deloitte (2000) Figure 24. Insurance companies, positioning opportunity Figure 25. Changing values in physician-patient relation Figure 26. Yhaoo health major categories Figure 27. Support groups value position Figure 28. Creating and using EMR in UK. Source: Bell (2000) Figure 29. E-procurement Figure 30. Pharmaceutics information E-channels. Source: Hudson (2000) Figure 31. Pharmaceutical supply chain Figure 32. E-disintermediation in pharmaceutical Supply Chain Figure 33. Pharmacy2U Internet site Figure 34. Online Pharmacy purchase in the UK. Source: Tucker (2000) Page 9

10 Figure 35. UK health sector. Source: Béresniak and Duru (1999) Figure 36. France health sector. Source: Béresniak and Duru (1999) Figure 37. Denmark health sector. Source: Béresniak and Duru (1999) Figure 38. Swedish health sector. Source: Béresniak and Duru (1999) Figure 39. Portuguese health sector. Source: Béresniak and Duru (1999) Figure 40. Saudeglobal, Portuguese health portal Page 10

11 Index of Tables Table 1. Health market players. Source: Empirica and WRC (2000) Table 2. Interoperations among health care players. Source: Empirica and WRC (2000) Table 3. Health expenditure growth. Source: OECD Health data Table 4. Health spending as % of GDP. Source: OECD Health data Table 5. Major changes in health Providers business Table 6. Survey of Telecoms positioning in Telemedicine. Source: Telemedicine Today (1996).51 Table 7. Major changes in Telecoms health business Table 8. Country s Telemedicine development stage. Source: Wright (1997) Table 9. The four C s model Table 10. Aventis e-procurement expectations. Source: Bradley (2000) Table 11. Aventis expected benefits from his value net. Source: Bradley (2000) Table 12. Total expenditure on pharmaceutical goods % Total expenditure on health. Source: OECD Health data Table 13. Major changes in Pharmacy business Table 14. E-health services, assessment frame Table 15. E-health related risks Table 16. E-health related expenditure Table 17. Financing Models in EU countries. Source: Empirica and WRC (2000) Table 18. Financing Models in EU countries. Source: Empirica and WRC (2000) Table 19. Support Groups Table 20. Online CME Table 21. Contact Centres Table 22. EMR Table 23. E-procurement Table 24. Risk assessment tolls Page 11

12 I. CHAPTER I - INTRODUCTION Internet emerged in the last years as a new, global, robust interactive channel, supporting all the characteristics to be used as a self-service long distance tool, and as enabler of closer relation between business partners. Being a rich source of multimedia information, highly interactive and 24 hours available, it allows real time answers to consumers requests. These characteristics help Internet players to develop a mass-market-of-one, where it s possible to identify consumers habits and preferences, tailoring the offer according to individual profile in micro market segmentations. The impact in social, cultural and business habits continuos to grow, as more and more PC usage becomes vulgar and new access technologies like WAP, PDA or WebTV emerged. Across most sectors, companies have made a move into Internet business, benefiting from venture capitals expectations and enthusiasm. But on a euphoric, technological driven market, a growing number of bankruptcies suggest some immaturity, and a need to join good technological innovations with appropriated business plans, that can balance the speed of technological obsolescence with short time payback. Slywotzky (1995), states that a company capacity to generate value is not in her technology, but in the way it s business design is able to manage people and technology to gain opportunities and generate profits. As well as products, business designs go through cycles from growth through economic obsolescence. Customer priorities, more than any other variable (even technology) has a natural tendency to change, while business designs tend to stay fixed. When company s business design and customers priorities fail to match, value migration begins to occur, leading to new business designs while killing fix and slow to adapt, traditional ones. Internet is a killer of slow, physic, isolation and market-share business models. The drivers are now connectivity, speed and personalization, McKnight (2000). Customer priorities go to convenience, reliability and customisation. Low price, quality and information are now assumed values. In some sectors like healthcare, the traditional height of presential human relations, as well as process specific needs, have delayed the Internet revolution. But even here, customer priorities have change and probably will continue to. New business designs, involving none traditional partners, are imposing them selves, in horizontal and vertical areas like home care, health information, continuous medical education (CME), drug prescriptions, health monitoring, second opinion and even in remote operation guidance. From a stage of presential, one-to-one personal relations, highly dependent on individualised experience and evaluations criteria s, health has evolve into more objective Page 12

13 means of diagnosis that had less to do with the subjective experiences of the particular physician, and more to do with the extent to which a patient typified a particular pattern of disease. This shift from a high reliance on direct communication to a reliance on information in the practice of medicine, has been technologically supported by the gradual introduction of new diagnose tools and methods of recording and quantifying physiologic conditions. Presently health care is one of the largest sectors in OECD countries, and accounts for over 8% of GDP on average. Only in EU, OECD statistics state that 370 million citizens, consult 5 times a year, one of the practising medical doctors. In turn this generates activity for the EU pharmacists, the 1.6 million nurses and also for many clinical-test laboratories and hospitals. In such a perspective and considering it s impact among other sectors in information exchange, work-flows and business partners relations, Internet his expected to have a strong impact in the organisation of health care, and by virtue of the volume of its transactions, in e-commerce numbers. However, even though health care promises to be a very significant part of Internet activity on par with its 8% share of GDP and in line with the growth of home care and consumers empowerment, it is to be expected that its integration will be a slow process. The main reason lies in its specific reimbursement structure where third party payers (be it private insurance, a NHS or social security), play an important role between the patient (the buyer), and the health care provider (the seller). As a consequence each transaction is subjected to a set of complex rules and regulations not only differing among countries or states but also depending on circumstances (e.g. emergencies). Moreover, because of the specific consequences of a breach in privacy in health care transactions, confidentiality and security issues require special measures, eventually only found in the online financial activities. To better understand all the key variables involving the introduction of Internet into the health sector, in the following pages a general overview and assessment of the current state of US and EU health markets, will be conducted, focusing in drivers barriers and expectations. This will be followed by a general overview of Internet development stage, and changes caused by its introduction on other market sectors. The chapter will end by defining this work research question, and proposing a methodology to evaluate risen hypotheses. Page 13

14 I.1. Health markets - General overview The health care sector comprises a complex mix of institutions, business, professionals and users, whose role and formats, changes among countries, according to politics, economics, social and cultural factors, as well as technological development. Empirica and WRC (2000) suggests that health care systems can be fragmented in five levels: MAIN TYPE SHORT DESCRIPTION EXAMPLES Direct heath care providers Consumers Educational and support services Purchasers / funders Policy / administration These are individuals or organisation that provide direct health care services, such as diagnosis, treatment and rehabilitation. These are the users of health care services. It includes the general citizen with health care interests. These are the services that provide initial and ongoing training for professionals, and those that provide general information. These are the organisations that pay for the health services that are provided to consumers. These are the agencies that manage the overall health care sector and the various players. - Office-based doctors - Health centres - Hospitals - Laboratory facilities - Pharmacies - Other paramedical / sociomedical services - Patients and Families - Students - General Citizens - Medical schools - CME services - Information and other support services for professionals or consumers. - National and local governments - Public insurance organisations - Private insurance organisations - Health Ministers - Local authorities - Various other public agencies Table 1. Health market players. Source: Empirica and WRC (2000). All this players interact with each other at some level, which can include legislation, information exchange, fee negotiation, payments, etc. These interactions are briefly resumed in the following interoperation matrix: Direct heath care providers Consumers Educational and support services Purchasers / funders Policy / administration DHP C ESS P&F P&A - Information - On-site - Billing - Consultation education - Payments - Treatment - Initial and CME - Clinical information - Patient referral/transfer - Support - Prescription - Peer support - Information and expert support - Health information - Remote education / training - Claims - Paymentt - Inter agency reimbursement - Activity reporting - Notifiable diseases - Activity reporting - Information exchange Table 2. Interoperations among health care players. Source: Empirica and WRC (2000). Page 14

15 The type of players existing in each market and the established relations among them defines the nature of the market. Béresniak and Duru (1999) propose two opposite philosophies of players and flux combination, representing the public and private models: Taxes COMPANIES STATE Taxes POPULATION Wages negotiation,... Health functions Lists inscription HOSPITAL SPECIALIST PHARMACISTS GENERAL PRACTITIONER PUBLIC SECTOR Freedom of choice POPULATION Insurance prize Health check Freedom of choice Reimbursement PRIVET INSURANCE COMPANIES Direct Payment Publicity HOSPITAL SPECIALIST PHARMACISTS GENERAL PRACTITIONER PRIVET SECTOR STATE - Rules implementation Figure 1. Health sector structures. Source: Béresniak and Duru (1999). Both models presume state intervention, with major differences in the providers dependence and funding mechanisms as well as in access to care. In the first model, health care is a public managed and owned service. It s expected to find a strong government control, intervening at the providers level, with strategic orientations, management, wages negotiation, etc. The state has the financiers role, supported by tax collection or other financing mechanism, and usually owns the facilities. In this specific model consumers freedom of choice is usually limited. On the second model, providers are mainly private institutions, with full management and strategic autonomy. State intervention is limited to regulation activities to ensure service and prevent/correct market failures. Eventually state co-financing of health care services might occur, but private institutions, insurance companies, associations, syndicates, and individuals now represent the gross of the financing mechanisms. The population power of choice grows both in the capacity of selecting a provider, as well as in the possibility of choice of financing models, (Béresniak, and Duru 1999). Usually there is a mix of both models, with more or less predominance of one. Palm et al (2000), state that the current forms of public social protection emerged in the in the Industrial society context, with the initial model of mutual benefit societies of the 19th and the first half of the 20th century. Public protection developed on the basis of two models: - Compulsory Social Insurance. The first law instituting the principle of compulsory social insurance was passed in Germany in 1881, and it make sickness insurance compulsory for both workers and employers with related contributions based on earned income. Protection was initially limited to wage-earners. Page 15

16 - National health services. This model was introduced in the UK in 1948, on the basis of four essential principles: coverage of the whole population, universal protection providing safeguards irrespective of the risk, a unified system supported in centralised national administration, and uniformity of benefits, matching response to need. All European countries have based the structure and funding of their health systems on one of these two public approaches, with different further evolutions resulting from historic and institutional developments of each country. While in Europe, the predominance is still for the public sector model, in the US, private sector model has been adopted. I.1.1. US Health Sector In the US, Federal Government is responsible for defining health practice guidelines, ensuring public health and safety, creating and disseminating public information, and educating public about health. In his turn, each state, through his medical board, has the power to adopt laws to protect and regulate health activities. The federal government is one of the major providers of health care services through institutions like the Department of Defence, the Department of Veterans Affairs and the Indian health Service. The federal government is also a major insurer through Medicare Medicaid and the State Children s Health Insurance Program (SCHIP). The US health insurance is a voluntary market. Coverage is found in both the public and private sector, though public sector coverage is limited to particular categories of individuals. The elderly (those age 65 and over) as well as disabled persons meeting specific eligibility requirements receive coverage through the Medicare program. Some groups of low-income persons are eligible for benefits through the Medicaid program (a jointly-funded, Federal-state health insurance program) with eligibility and included services varying significantly by state. Other public programs, such as the military health system, provide insurance for some narrowly defined populations. Another example of public coverage is state-sponsored high-risk pools. Risk pools provide insurance to individuals who, as a function of pre-existing illnesses or conditions, have been denied private insurance coverage. Generally, only the basic and emergency care is fully covered under public insurance plans. Other types of care require patients co-payment or the existence of a second health insurance plan. Private Insurer companies base their premium and coverage policy in patients risk assessment tests. Private sector coverage includes those people who are ineligible for public sector coverage, people who choose to supplement their public coverage with additional private insurance, and people who choose to purchase private coverage Page 16

17 despite being eligible for public programs. Patients can choose and manage their benefits, directly (self-insured), through workers and syndicates associations or joining companies health plans. Since medical providers typically collect a co-payment from the patient and bill the patient s insurer for the remaining cost of the service, patient access to care (although not limited as they can choose to support all expenses) might entail eligibility verification and pre-service authorisation. Health providers (professionals and/or institutions) are mainly in the private sector. Directly or through associations, they established conventions with existing health plans, defining levels of coverage and costs for each type of service. Medical practice is regulated by states and federal laws. States regulate licensure and practice issues, with criteria s changing from state-to-state. Some states adopted a policy of mutual recognition of health professionals, but in most cases if the practitioner chooses to work in a different stage, another licence must be obtained. Patients access to care in non-resident states is also conditioned to health plans specifications. I.1.2. EU Health Sector Within EU, the organisation and delivery of health services and medical care have always been considered a responsibility of each member country. Although since the Maastricht treaty, the achievement of a social and health protection has been established as one of the aims of the union, unions role should be of ensuring that the European environment is supportive of optimal health promotion and protection, but with no direct intervention in local policies. The private or public nature and importance of financing and delivery of health care services, varies among EU countries. Although most health care expenditure is public sector originated. Analysing EU health care systems, Palm et al (2000), proposed a model to group countries public access to health: Social insurance systems generally offer category-based protection. In Belgium, there are two separated regimes: the first covering the whole population apart from the selfemployed and the second covering only the self-employed. In France, there are three regimes: for employed workers and civil servants, for the self-employed and for farmers. In Germany, those with incomes above a certain level are not subjected to compulsory Page 17

18 insurance. In the Netherlands, those with incomes above a certain level are excluded from the public system. ACCESS TO HEALTH CARE SOCIAL INSURENCE NATIONAL HEALTH SERVICE REIMBURSEMENT BENEFITS IN KIND CENTRALISED DECENTRALISED B A UK E P SW F D IE I DK L NL GR FIN Figure 2. Typology of the public health care systems in the EU. Source: Palm et al (2000). In the countries with social insurance, two systems for meeting medical costs may be distinguished. One grouped comprising Belgium, Luxembourg and France, reimburses the cost of health care services. The insured person has a free choice of health care provider. In the other group, formed by Austria, Germany and Netherlands, the social protection system ensures that the patient receives the care his state of health requires. In these countries, the general practitioner behaves as a gatekeeper, he refers the patient to other forms and levels of care. In the countries with national health services, delivery of health care and ensuring its access are managed by the state in a centralised or decentralised mode. Generally the patient has no out-of-pocket payments to make except for any standard charges. Coverage is usually universal, and most of these countries fund their systems from taxes In some countries, access to specialists or higher levels of care, must be conducted through a GP, that acts like a gatekeeper. This gets reword in a per-service fee or in percapita bases. The UK, aiming to control health expenditure and increase competition among providers, established a especial philosophy of budgeting, where the GP- Gatekeeper, receives a budget according to his patients list, and manages that budget contracting services to other providers (exams, hospitalisations, surgeries ). 1 At the present, the bulk of health care provision and expenditures occurs within national boundaries, however cross-border activity does exits. Empirica and WRC (2000), state that the scale of cross-border care is quite small but suggest that the evolution for a single 1 Higher detail of some EU countries market structure can be found in appendices A. Page 18

19 market will ease and encourage transactional health care with necessary implications in political and financing mechanisms. Palm et al (2000), analysing two judgements of the Court of Justice of The European Communities (cases Deker 1998 and Kohll 1998), where the court decided that social security systems of patients countries should reimburse medical services provided in another member state, pointed some major reactions: - The press, standing for the consumer, welcomed these cases as a social improvement for patients, a step forward in the right of European Citizens and a positive advantage in the process of creating an internal market in health care. - Member states saw the court decision as encroaching their prerogative of organising their protection and health systems in accordance with their own choices, operating rules and criteria for access to treatment and quality of care. They questioned if the rules of free movement of goods and provision of services enshrined in the treaty would be applicable in the field of social security given the competence of the member states in this domain. Most governments also feel that unrestricted access to health care abroad would endanger policies for containing health expenditure, for allocating resources effectively and for public health care. - Social security administrations considered that the exceptions created rise administrative complications and legal uncertainty. To Palm et al (2000), the importance of this two judgements, transcends the question of cross-border care, affecting the relationship and balance between the economic freedoms enshrined in the EU treaties which manage the internal market (and the health care sector), and the basic principles of social protection (ensuring access to health care), organised at a national level. Page 19

20 I.1.3. Demand Offer relation Demand and offer articulation in the health sector does not obey to the common economical roles. Health is not a common good able to be consumed, spent, exchanged or re-sold. Health care providers in general terms, benefit from the privilege that most of their clients, are reimbursed in their purchases, and have no reluctance in using it. Plus, most consumers lack the information necessary for informed choice, (Oxley and MacFarlan, 1994). As so, health demand becomes highly influenced by financial, cultural and demographic factors, which can easily cross and even overlap. According to Béresniak and Duru (1999): - Finance influence: Usually the basic health insurance programs don t cover all health expenses, driving population to private health insurance s to obtain full indemnity and risk cover. The intervention of an external financial mechanism, like a private health insurance, changes the balance between supply and demand, causing that the applied tariff doesn t represent the real market prices. The consumers paid price will decrease while increasing the producers collected price, resulting in an over production and consumption, of health care. - Demographic influence. Demand for health care doesn t have a linear distribution among population. Population can be segmented in different categories, based on consumption patters, with age and sex being major differentiation variables. Other influence factors are associated with the planing and allocation of health cares institutions and professionals, which is usually planed with base on simple indicators like number of health professionals per capita, number of beds per capita, etc. Although is presently recognised that this procedures are quite inefficient because medical activity requirements change from country to country and even between regions, their simplicity and easy of implement, justifies their large utilisation. - Cultural influence. Life behaviours with more or less exposition to risk factors, and with different reactions when dealing with health problems can determinate illness early detection and treatment. Higher classes are usually responsible for higher demand of ambulatory services and less hospitalisation, in opposite to what happens in disfavoured classes. The fact that health demand is continuously growing is well documented and justified, based on the development of medical knowledge as well as therapeutics and technological improvements that results in a growing of life expectation and quality. Nevertheless, Béresniak and Duru (1999), suggest the existence of an induced demand situation in the health sector. The higher the offer the higher demand will be: Page 20

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